Health Concerns and
International Adoption

Reprinted with permission from Passport
Health

Foreign adoptions
are on the rise. From 1989 to2002, U.S.
families adopted more than 167,000 children internationally. In 2002, U.S.
citizens adopted 20,099 children from 20 countries. During the past decade, the
countries from which most children have been adopted have changed. In 1989,
children were adopted most frequently from
Korea,
Colombia,
India,
the Philippines,
and
Chile.
By 2002, only Korea
remained in the list of top five countries;
China,
Russia,
Guatemala,
and the Ukraine
replaced the other four countries. This shift can be associated with a change in
disease epidemiology in adopted children. The outbreaks of severe acute
respiratory syndrome (SARS) illustrate the dynamic relationship of infectious
disease and travelers and the need to have up-to-date information. In April
2004, the Centers for Disease Control and Prevention temporarily suspended
adoption processing from an orphanage in
China’s
Hunan
Province after nine cases of measles in recently adopted children were determined. This
is the second time since 1997 that the agency suspended foreign adoptions. The
previous suspension occurred in February 2001, and was also related to measles
outbreak that originated in a Chinese orphanage. These events demonstrate how
adoptive parents must be tuned in to a range of healthy issues that can arise
with foreign-born children. Parents should select a pediatrician who knows how
to recognize childhood diseases that are becoming less familiar to doctors in
the U.S. Measles is one of the most infectious diseases in the world, but the
U.S.
sees fewer than 100 measles cases a year on an average, mostly imported from
other countries.

The families of internationally adopted children face health
risks associated with travel when picking up their adopted children overseas.
Unlike other travelers, they may be at increased risk because the child’s
immunization status is often unclear and these children may harbor infections.
Tuberculosis, hepatitis A, hepatitis B, and measles have been transmitted from
adoptive children to family and community members. Intestinal parasites and
other infectious diseases can also be transmitted. Some of these infections may
not manifest in adopted children until many years after the adoption.
Practitioners providing health care to families planning international adoption
should know about standard pre-travel advice, as well as possible infections
that may affect adopted children. By doing so, they can protect the health of
the travelers, family members and close friends who will welcome the new child
into the home.

Adoptee's often arrive in the U.S.
without in-depth information on the past medical history or social environment.
Records are frequently unavailable, offer little information, or sometimes, even
falsely recorded. Records that seem “too perfect” are often times, just that.
Even when vaccines have been given reliably, the immune response may have been
inadequate in severely malnourished or chronically ill children. When in doubt,
it’s always best to repeat the series of vaccinations, as there is no harm in
re-immunize internationally adopted children against the vaccine-preventable
diseases specified by immigration law, and to screen them for HIV, tuberculosis,
parasites, and hepatitis C. U.S. law passed in 1996 requires all immigrants
applying for a permanent visa to show proof of immunity of several
vaccine-preventable diseases, such as measles, mumps, polio, and hepatitis B.
The law has been amended and now exempts adopted children under 11 years of age.
Proponents of this amendment argued that the requirements placed an unnecessary
burden on children and lengthened what is already a heavily bureaucratic and
emotionally exhausting experience for the adoptive parents.

In addition to following through on screening and
vaccinations, parents of newly adopted children should cocoon for a few weeks
after their arrival at home. Even though this is a time when it is customary to
show off the newest member of the family, it is especially important in those
initial weeks to minimize contact between the child and family members of
friends who have compromised immune systems. About one-half of internationally
adopted children will have an acute illness within the first month after
arrival. The first response of the new adoptive parent is to rush the child to
the physician for a full check-up. Most early illnesses are simple pediatric
conditions, such as URI (upper respiratory infections), gastroenteritis or skin
infections. It is advisable to follow all acute illnesses closely to resolution.
Failure to improve as expected, or to resolve completely may be the first
indication of an underlying condition. Among those conditions that would warrant
immediate attention are some vaccine-preventable diseases and malaria, depending
on the origin of the adoptee.

Although hepatitis B vaccine programs are public health policy
in some countries, the circumstances that leave a child available for adoptions
are the same as those that afford the child the least access to medical care.
Some experts advise against screening children before adoptions as the testing
process itself may be yet another source of infection. The screening results may
also be inaccurate or misinterpreted.

Tuberculosis (TB) remains a significant problem among
adoptee's. It is prevalent in many host countries and is a silent infection in
children. All children should be screened at arrival and at any time they
develop systems compatible with TB. Routine ppds (purified protein derivative)
are often mandated.

Until recent years, HIV infections had not been a major issue
in international adoption. Now, adoptive parents are presented with a new
dilemma about pre-adoption screening.

In order to protect the adoptive
families, immunization records of travelers should be reviewed to update routine
vaccinations such as measles, tetanus/diphtheria and polio. Travelers to most
parts of the world will benefit from protection against hepatitis A and B. In
areas where safety of food and water cannot be guaranteed, protection against
typhoid is also desirable. Travelers to parts of Africa and
South America where
yellow fever is epidemic should receive yellow fever vaccine and information
about preventing mosquito bites. Individuals traveling to parts of Asia and
the Indian subcontinent in the rainy season may be candidates for Japanese
Encephalitis, especially if travel includes rural areas during transmission
season. Rabies is a serious problem in parts of Asia, Africa, and Latin America
and is present in Eastern
Europeans well. Adoptive families
planning extended travel to remote areas should be advised to avoid befriending
animals and should consider pre-exposure rabies.

Families traveling to areas where malaria is present should be
protected against malaria. Using insect repellant's with 20% to 30% DEET and
permetherin spray for bedding and clothing can significantly reduce exposure to
mosquitoes. Choice of an anti-malarial agent depends on the destination country,
medical history, length of stay, and to some degree, personal preference.

As the number of international adoptions continues to
increase, so does the need to protect adoptive families, not just for those who
are traveling, but also in the entire household. Pre-travel evaluation of
adoptive families should include updating routine immunizations including the
hepatitis B series for all family members. Pre-travel advice should include
country specific health and security information for the family members
traveling, instructions and supplies for the adoptee and preparation of
household members who will assist with the care of the child upon arrival.